Failure to Prevent Resident Fall During Incontinence Care
Penalty
Summary
A deficiency occurred when a resident with a history of nontraumatic intracerebral hemorrhage, diabetes, and heart failure, who was cognitively intact and required assistance from one to two staff for transfers and bed mobility, sustained a fall during incontinence care. The resident was being assisted by a single CNA, despite requiring up to two-person assistance, and the CNA rolled the resident away from herself, resulting in the resident falling out of bed onto the floor. The resident reported pain to the right upper and lower extremities and remained on the floor for approximately 30-45 minutes while staff located a mechanical lift to return them to bed. Documentation and interviews confirmed that the CNA was working alone and did not follow proper transfer technique, which was acknowledged by both the ADON and DON. Further review revealed that the facility's provided policy, titled "Accident and Incident Report," did not address fall interventions or prevention measures. The incident was witnessed by staff who responded to a loud noise and found the resident on the floor. The resident expressed concerns about the adequacy of assistance during transfers and bed mobility, and the lack of a comprehensive fall prevention policy contributed to the failure to prevent the accident.